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A manager is reviewing the nursing documentation entered by a staff nurse in a patient's electronic medical record and finds the following entry, "Patient is difficult to care for, refuses suggestion for improving appetite." Which of the following statements is most appropriate for the manager to make to the staff nurse who entered this information?

1. "Avoid rushing when documenting an entry in the medical record."

2. "Use correction fluid to remove the entry."

3. "Draw a singe line through the statement and initial it."

4. "Enter only objective and factual information about a patient in the medical record."

User Atlaste
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Final answer:

The manager should instruct the nurse to enter only objective and factual information about a patient in the medical record, ensuring professional and precise documentation.

Step-by-step explanation:

The manager's response to the nurse should emphasize the importance of maintaining professional and objective documentation in patient health records. Among the options provided, the most appropriate feedback would be to advise the nurse to enter only objective and factual information about a patient in the medical record. The manager should explain that the nurse's subjective statement could be interpreted as biased or unprofessional, and instead, the nurse should focus on documenting specific behaviors, actions, and statements made by the patient, using clear and factual language. For example, a more appropriate entry might be, 'Patient declined all food offerings during the mealtime assessment.' This kind of precise documentation can support interdisciplinary communication and improve patient care.

The most appropriate statement for the manager to make to the staff nurse who entered the information is 'Enter only objective and factual information about a patient in the medical record.'

When documenting in a patient's electronic medical record, it is important to provide accurate and factual information. Subjective statements, such as the patient being difficult to care for, should be avoided as they can be interpreted differently by different individuals. Only objective information, such as the patient's vital signs, symptoms, and interventions provided, should be documented.

Drawing a single line through the subjective statement and initialing it or using correction fluid to remove the entry are not appropriate actions. Rushing when documenting an entry can lead to errors, but that is not the main issue in this case.

User Kkakroo
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